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Keloids and Keloid Management

This audio podcast has been transcribed using an automated service.  Please forgive any typographic errors or other transcription flaws.

Today’s podcast is on keloid and how to manage keloids. For some reason over the years I have really become a specialist in keloids and I perform quite a few keloids almost every week. Keloids are something that people always use as a term that is used inappropriately. I hear all the time I have a keloid and I look and it turns out to be just a hypertrophic scar or a little bit of an elevated scar. So clinically what a keloid is, it is a scar that goes beyond the borders of the wound and that is something qualitatively where you would say is this big enough to be a keloid or not? And usually it’s significantly bigger than the actual incision itself. If it’s just mildly little elevated that’s a hypertrophic scar. The reason why that distinction is so important is that hypertrophic scars and keloids are managed completely differently. 


Of note also histologically, which means under a microscope, the keloid itself is also quite different because the collagen is completely disorganized versus hypertrophic scars where they are linear and organized. So there are completely different entities. So hypertrophic scars, which is not the subject of this discussion would be managed with silicone sheets with injection of steroids and 5FU (Fluorouracial injection) to reduce it. Whereas keloids really are don’t respond well to injections and they’re very, very hard to manage. If there’s small, they can be managed with a very high dose steroid mixed with 5FU (Fluorouracial). So compared to when I do hypertrophic scars, but oftentimes patients come to me after having failed this therapy. So for me as a surgeon, I find the most definitive way to manage keloids is to actually remove them if it is possible to move them.

Sometimes they’re all over the body. They’re so difficult that you really can’t take it out. But if there’s discrete areas that I can do it under minimal closing tension, then a surgery is the preferred way of doing it. However, just doing surgery, just cutting it out and not following it up with radiation therapy will actually lead to a disaster. The keloids will be significantly, significantly larger. So the other therapy that a lot of people do is cutting the keloid out and then after cutting the keloid out, they just inject it. And I find this, the success rate of that is actually quite low as well. And oftentimes the keloids wind up to be much larger. So for me, the definitive way of doing it is proper surgery, which we’ll discuss followed by timed radiation. The radiation must be performed within 24 hours after the close of the procedure and this and the radiation must be a low dose, a procedure done over three to five days by qualified radiation oncologist. 


There’s a question, is there a risk with radiation? And really besides possibly some skin changes, there could be some hair loss usually temporary in the area, but the most serious risk is as skin cancer or cancer in the area. And the odds from what I know are very, very, very rare low. However, it is always imperative and important to talk to the radiation oncologist about those risks before undertaking it. As a surgeon, here are some principles of keloid removal that are really, really important. First, it is complete removal of the keloid itself. I under a microscope, not under microscope, but under a microscopic loupe magnification I’m removing the keloids. So you want to take the whole keloid out is the first principle. The second principle is a closure without tension because with significant tension you can have a recurrence of the keloid as well. 


So how do I minimize recurrence? Excuse me, how do I minimize tension? Well, you can actually in nucleate the keloid by leaving the overlying skin in place. So what I usually do is I’m skiving down the keloid underneath the skin and checking for tension and then removing the amount of skin that I need to so that there’s a tension free closure as well as undermining around the area as well. The other principle is closing it in layers so that there’s less chance of tension as well as part of the whole thing. And the other principle with this is making sure that you don’t leave a deformity behind. And so I had a gentleman, I just remember about a year ago, in which I had done a keyloid. And when I saw him, he had not only recurrence from his other doctor, but he also had a look like, I hate to say this, Mike Tyson chewed off his ear because it had been, it had basically been just cut out without any sense of repair or reconstruction. 


So being a plastic surgeon, I’m very focused on the repairs so that the appearance of the area looks very natural. It doesn’t look to formed and that requires some tailoring of flaps and shaping so that everything looks normal. For example, I had a gentleman that had a keloid from gauge ear, so it looked very simple. In fact, my assistant said this looks pretty simple. You just cut out the keyloid from the gauge here and then you’re done. But when I took out the keloid, it left the gauge a deformity. So I had to do a reconstruction where I shortened the ear lobe and repaired it so it looked like a normal ear lobe. Otherwise he would have this long thin looking thing like looks like from Asian painting of an ear lobe, which would be terrible. 


So, you know, reconstruction is so very important. I tell all my patients that it’s so important to be vigilant in terms of prevention, sorry, prevention of recurrence. So prevention of recurrence requires feeling it, checking it, making sure as I coming back and the ways to minimize recurrence would be to catch it early to use pressure dressings on there. There are certain clips on the ears that work really, really well. I always tell my patients to buy those well in advance of even the surgery, put it on the good ear so that you can test how it’s gonna work, before you do it. And that’s critical. And then let me know if there’s an early sign of recurrence. If there’s early sign occurrence, we want to get to it before it becomes something difficult to manage and difficult to do surgically. 


The recurrence rate with this proper surgery technique and radiation in my hands is less than 10% in five years. And after the first year, if you get past it, the success rate goes from 90% to 95%. And if you get to five years, I never say it’s 100%, but I would say it’s probably 98% – 99% success rate. And you know, keloid removal can really be life changing, you know, if done properly. I remember really nice gentleman I hadn’t seen in many years and he came back to me and he said that he was too ashamed to even look at women. And after I took out these large football sized keloids off his neck he got engaged, got married in Las Vegas and was very, very happy and I could see the change in his face. So, that’s a short summary of keloids. There’s obviously a lot more information that can go into, but hopefully if you’re interested in keloid excision, this could be something helpful if your doctor is going to perform it or if you come to see me.